Can you? Visage can. Volume 1: Speed INTRODUCTION 3 CHAPTER 1: IMAGE DISPLAY 4 CHAPTER 2: 3D/ADVANCED VISUALIZATION 4 CHAPTER 3: DBT 5 CHAPTER 4: IN-VIEWER WORKFLOW 6 CHAPTER 5: AT-HOME/REMOTE READING 7 CHAPTER 6: REGIONAL ENTERPRISE IMAGING 8 CHAPTER 7: THIN-SLICE READING 9 CHAPTER 8: PRIORS 10 CHAPTER 9: STUDY INGEST PERFORMANCE 12 CHAPTER 10: MULTIPLE WORKFLOWS 13 CHAPTER 11: INTEROPERABILITY 15 CONCLUSION 17 Page 2 12625 High Bluff Drive, Suite 205, San Diego, CA 92130 (888) 998-4724 | www.visageimaging.com Introduction Visage’s General Manager, North America, Brad Levin, has recently published a series of new blog posts, Can you? Visage can., with the exciting first topic focused on Speed. We’ve aggregated the individual blog posts to create this whitepaper: Can you? Visage can. | Volume 1: Speed. It’s all about differentiation and value, and Visage offers distinction in a sea of PACS sameness. While Visage customers appreciate the unique value of Visage 7, we’re trying to make it easier for outsiders to get insights into why Visage is truly a generation ahead. Get prepared, we’re going to give you a peek into Visage 7 that goes beyond features lists and RFP responses, cutting to the chase, while filtering out jargon, buzz and hype. Speed is a topic that is near and dear to Visage. I think Dr. David Clunie said it best a few years ago at SIIM, when he commented that in Imaging, the top three requirements for any software application are, “Make it fast. Make it fast. Make it fast.” He was and remains spot on. Speed is central to Visage 7, but it’s actually much more than you’re thinking. More than just the rapid display of images, speed manifests itself in Image Display, 3D/Advanced Visualization, Digital Breast Tomosynthesis (DBT), In-Viewer Workflow, At Home/Remote-Reading, Regional Enterprise Imaging, Thin-Slice Reading, Priors, Study Ingest Performance, Multiple-Workflows and Interoperability. While other vendor solutions use trickery, restrictions and workarounds to ‘simulate’ speed to the end user, Visage 7 transcends speed expectations across the entire platform. Let me explain. Page 3 12625 High Bluff Drive, Suite 205, San Diego, CA 92130 (888) 998-4724 | www.visageimaging.com Chapter 1: Image Display The most prominent, visceral indication of speed is image display. For years in PACS, there has been an expectation that the time “to first image” needed to be 2-3 seconds. Some vendors met that requirement, most did not. And even for those that did, was the “first image” sufficient? What about the entire dataset? If you wanted to view a specific image or series of images, users often had to wait for the entire dataset(s) to load. Some solutions implemented local/auto-caching to the client/workstation, to trick the user into believing that the viewer was fast. But if the current/prior dataset was not local, you still had to wait for the data to download. And for double-digit gigabyte sized datasets, that’s an impossibly long wait. Given these limitations, time to first image is a false metric of speed. Visage 7 never caches images to the local disk, and yet, is incredibly fast. How fast? Visage tracks a key performance indicator (KPI) for our largest customer in the world, with a single production Visage 7 Backend Server (also replicated in a remote datacenter for High Availability), currently processing 2.8M annual new studies (growing to 3.8M across the system) as well as millions of priors, across dozens of distributed, regional hospitals. Their median display time to view the entire study, across all imaging modalities, across all study sizes, is 1.1s. While there are outlier studies that may take longer than 1.1s, this KPI is based on production Visage 7 customer data, at massive scale, spanning all diagnostic and clinical workflows, across all sized studies. Let me repeat: 1.1s. This is no myth, but verifiable truth. Chapter 2: 3D/Advanced Visualization In Chapter 1 of Speed, we discussed why Image Display is the immediate reflex most people think about when considering the speed of enterprise imaging. While it may begin with Image Display, it does not end there. In this post, we'll continue the conversation into Chapter 2: 3D/Advanced Visualization. To this day, many legacy PACS cannot display advanced visualization reconstructions or VR images, within their core viewer(s). The user must launch a third-party application to view additional multi-dimensional images. If the images are not on the third-party server, the user has to wait for the data to be transferred, be processed, and displayed. In most cases this delay is intolerable, so much so that radiologists ask that static secondary captures be generated at the modality console or workstation. And even for those rare vendors that do support advanced visualization in their viewers, often the advanced visualization tools are a plugin, with a different workflow and look and feel, slowing the user down. Visage 7 pre-processes cross-sectional image data at the server (CT, MR, PET/CT, PET/MR, DBT, etc.), and when the user requests current and prior(s) for display on-demand, all of the images are immediately available for multi-dimensional display in the protocol. Page 4 12625 High Bluff Drive, Suite 205, San Diego, CA 92130 (888) 998-4724 | www.visageimaging.com Visage 7: MRA and MRV 100% of Visage’s advanced visualization features are native Visage code. With Visage, the haves and the have-nots are a thing of the past. Referring physicians who require radiologist caliber tools, including 3D/advanced visualization, have access without additional cost, limitation or any performance impact whatsoever. Chapter 3: DBT In the first two chapters of Speed, we discussed the topics of Image Display and 3D/Advanced Visualization. Many may think that speed of image display and having access to 3D views are most important; however, the size of imaging studies continues to grow and grow. A few years ago, cross sectional imaging made its way to mammography and far too many imaging organizations continue to struggle with their infrastructure, workflow, and interpretation. How important is speed? Not too long ago we were at a demo at a large outpatient imaging chain, when the next radiologist on the schedule sat down for their demo. She immediately said, "Is it ok if I drive?" She clicked on the study and immediately the DBT painted the viewports of the multi-headed display. She froze with delight, literally. Without saying a word to anyone, she 'dropped' the mouse and shuffled out of the room in absolute amazement. When she came back a few moments later, all of us were puzzled by her reaction. She paused and said, "You have to excuse me, as I've been struggling with DBT for a long, long time. What I just saw impressed me so much I just had to leave and compose myself. Now, let me do that again!" With that experience as the context for what is possible, in this post, we'll continue the conversation with Chapter 3: DBT (Digital Breast Tomosynthesis, DBT or “tomo”). Page 5 12625 High Bluff Drive, Suite 205, San Diego, CA 92130 (888) 998-4724 | www.visageimaging.com With Visage 7, DBT is just another modality, no separate module or workstation required Even today, many legacy PACS do not support DBT at all. And those legacy PACS that do support tomo do so with significant limitations. How so? Speed of image display, restricted access to priors, the need for a dedicated DBT archive, the need for dedicated DBT workstations, the need for significant network augmentation, the need for workflow modification (e.g., perform procedures in the AM, move priors all other hours in advance of the next day) are all limitations we frequently hear about regarding legacy PACS support of tomo. For Visage 7, DBT is simply another modality, requiring no workarounds or dedicated workflows whatsoever. Visage 7 supports the display of DBT along with DBT priors and multimodality presentation of all breast imaging studies (MG, DBT, Breast MR, Breast US, AWBUS), or any modality for that matter, from both Windows or macOS clients. Due to these capabilities, Visage 7 is able to eliminate the need for expensive, restrictive, dedicated breast imaging workstations. Despite moving upwards of tens of gigabytes of data for current and prior requirements, Visage 7 is able to display the required data incredibly fast for interpretation, local or remote. How many enterprise imaging platforms are able to support remote DBT reading at scale and eliminate dedicated workstations? We’re not aware of any system…..other than Visage 7. Chapter 4: In-Viewer Workflow In our last chapter, we discussed how DBT ("tomo") has paralyzed many imaging organizations due to its massive files, but for Visage, tomo is just another modality. What we have learned in practice is that speed is relative. In this post, we'll explain what we mean, by continuing the discussion with Chapter 4: In-Viewer Workflow. Many legacy PACS do not have reliable, usable hanging protocols. So much so, many institutions have given up trying to improve them. We know that historically the majority of unproductive time spent during legacy PACS radiologist interpretation is to setup a case in order to begin "reading". Finding ‘relevant’ priors, dragging and dropping images/series/studies, panning, zooming, linking, W/L, etc. This is incredibly time consuming, and yet, for many PACS, this is required prior to reading every new study. What does it matter if the image viewer is able to display the first image in 2-3 seconds, if the reading radiologist has to spend tens of seconds to minutes, preparing the studies prior to starting interpretation? What does it matter if the image viewer is able to display the first image in 2-3 seconds, if the user has to travel to a specific workstation, which may be local (via walking distance) or remote (travel by vehicle), to use the appropriate clinical tools or access the relevant priors they need? As mentioned, speed is relative.